Information Collection

COVID-2019 Referral Slip

IC 239870 under ICR 202001-0920-020 · OMB 0920-1287.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1287 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-20HF COVID-2019 Referral Slip	Form and Instruction
0920-20HF Referral Slip Attachment I COVID-2019 Referral Slip-2.10.2020_Final.docx	Form and Instruction

IC Title:

COVID-2019 Referral Slip

Agency IC Tracking Number:

0920-20HF

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-20HF	Referral Slip	Attachment I COVID-2019 Referral Slip-2.10.2020_Final.docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	300,000	300,000
Annual IC Time Burden (Hours)	25,000	25,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.